For Office
Use Only
Received: No. on Record:____________ No. of Claims: Cheque No.: _______
Max. Amt: Amt.
Reimbursed:
_________________ Amt. Remaining: __
Initials: Administrator __________ Cheque Signer _______
Mental Health Fund (MHF)
(September 2019 - August 2020)
PSAC Local 610
Western University
1313 Somerville House
London, ON N6A 3K7
Phone:(519)661-4137 e-mail: staffpsac610@gmail.com
Web: www.psac610.ca Fax: (519)850-2998
You may fax, email, mail, intercampus mail, or drop your application off in the office at 1313 Somerville House. There is also a drop box beside
the office door for after-hours business.
Last Name: First Name:
Student Number: E-mail:
Address:
City:
Province:
Postal Code:
I am unable to collect my cheque from the office, please mail it to the above address.
TOTAL AMOUNT TO CLAIM FROM MHF:
(10$ minimum claim amount)
The MHF is a supplemental health plan intended to supplement a primary insurance plan; for most GTAs this is the SOGS
Health Plan. The MHF will only accept claims that you have submitted to a primary insurer or that you can demonstrate will
not be
covered by your primary insurer.
Yes, I have already applied through SOGS or another insurer and have attached the insurance statement.
No, I did not apply through SOGS because (please explain):
(Ex: maxed out of SOGS Health Plan)
Member Information
Please indicate which term(s) you are a TA for this academic year:
Fall Term Winter Term Summer Term
If you are applying for a family member, please fill out the information below:
Last Name First Name
Relationship
Receipts and insurance claim statements (copies are acceptable) sufficient to identify the nature, cost, and amount you
have been reimbursed for each item in your claim.
GTA contract letter or signed duties specification letter indicating your work during the policy year. This information is
usually on file by the middle of a given term and you do not need to provide this information if it is already on file.
Contact the Administrator if you are unsure.
I hereby certify that, to my knowledge, the contained information is correct. I also understand that the information and
supporting documents provided here are for administration purposes only and will be kept confidential by PSAC Local 610.
Signature of Applicant:
Date:
